Clearance and Nutrition in Neonatal Continuous Renal Replacement Therapy (CRRT) Using the CARPEDIEM™ System

Abstract

Abstract Background: Infants with end stage kidney disease (ESKD) demonstrate poor growth partly due to obligate fluid and protein restrictions. Delivery of liberalized nutrition on continuous renal replacement therapy (CRRT) is impacted by clinical instability, technical dialysis challenges, solute clearance, and nitrogen balance. We analyzed delivered nutrition and growth in infants receiving CRRT with the Cardio-Renal, Pediatric Dialysis Emergency Machine (CARPEDIEM™). Methods: Single center observational study of infants receiving CRRT with the CARPEDIEM™ between June 1 and December 31, 2021. We collected prospective circuit characteristics, delivered nutrition, anthropometric measurements, and illness severity Score for Neonatal Acute Physiology-II. As a surrogate to normalized protein catabolic rate in maintenance hemodialysis, we calculated normalized protein nitrogen appearance (nPNA) using the Randerson II continuous dialysis model. Descriptive statistics, Spearman correlation coefficient, Mann Whitney, Wilcoxon signed rank, Receiver-Operating Characteristic curves, and Kruskal-Wallis analysis were performed using SAS version 9.4. Results: Eight infants received 31.9 [22.0, 49.7] days of CRRT using mostly (90%) regional citrate anticoagulation. Delivered nutritional volume, protein, calories, enteral calories, nPNA, and nitrogen balance increased on CRRT. Using parenteral nutrition, 90 ml/kg/day should meet caloric and protein needs. Following initial weight loss of likely fluid overload, weight gain occurred after 14 days of CRRT. Despite adequate nutritional delivery, goal weight (z-score=0) and growth velocity were not achieved. Most (62.5%) survived and transitioned to peritoneal dialysis (PD). Conclusions: CARPEDIEM™ is a safe and efficacious bridge to PD in neonatal ESKD. Growth velocity of infants on CRRT appears delayed despite delivery of adequate calories and protein.